Medical Consent & Telehealth Consent

Last Updated: December 1, 2024

This consent form provides you with information about telehealth and seeks your permission to receive medical care from healthcare providers ("Providers") through the LumiVera platform. Please read this form carefully and ask any questions you may have before signing.

1. Nature of Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Live two-way audio and video
• Output data from medical devices and sound and video files

2. Benefits and Risks of Telehealth

Benefits:

• Improved access to medical care by enabling a patient to remain in their home while the provider consults from a distant site.
• More efficient medical evaluation and management.

Potential Risks: As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the Provider.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

3. Consent to Treatment

By signing this form, I attest to the following:

1. I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care or treatment.
3. I understand the alternatives to telehealth consultation as they have been explained to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the care involving physical tests may be conducted by other healthcare professionals at my location at the direction of the consulting Provider.
4. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.

By completing the intake process, I acknowledge that I have read and understood this Medical and Telehealth Consent, and I voluntarily consent to receive medical care via the LumiVera telehealth platform.